Cough Flashcards
how long is acute cough?
less than 2 weeks
What are the differentials for acute cough, not in distress?
ID: URTI, Pneumonia, COVID, Croup
Non-ID: Asthma
What are the differentials for acute cough, in distress?
COVID
Bronchiolitis
Pneumonia
Asthma, BAIAE
Foreign body
Laryngotracheitis
Epiglottitis
Tracheitis
What is acute upper respiratory tract infection?
Common cold
“rhinitis”
What is the etiopathogenesis of common colds?
- Children have an ave of 6-8 colds per year
- Infection is primarily due to viral exposure
- Patho: PND, hypersensitivity of afferent sensory nerves
secondary to inflammatory mediator release
What are the etiology of common colds?
Rhinovirus (>50%), coronavirus, RSV, human
metapneumovirus, adenovirus, parainfluenza
- Mechanism of spread:
§ Direct hand contact
§ Inhalation of small particle aerosols
(influenza, coronavirus)
§ Deposition of large-particle aerosols form
sneezing that land on nasal or conjunctival
mucosa
What are the clinical manifestations of common colds?
CM:
1. Infants: nasal discharge, fever
2. Sore throat, sneezing, nasal obstruction, rhinorrhea,
irritability, dec. appetite
3. Cough - usually begins after nasal sx and may persist
for another 1-2 w after resolution of other sx
4. Fever – influenza, RSV, metapneumo, adeno
5. Colds x 1 w
6. Sx onset usually 1-3 days after viral infection
7. Swollen erythematous nasal turbinates – acute rhinitis
8. Mildly erythematous pharynx – acute nasopharyngitis
9. Anterior cervical LNE or conjunctival injection
Diagnosis of URTI/Common colds?
- Usually clinical
- r/o sinusitis, foreign body
What is the management of common colds?
- supportive – inc OFI; topical nasal saline or saline nasal
irrigation to reduce sx - herbal meds – strong evidence for: Andrographis
paniculata, ivy/primrose/thyme - honey – superior to usual care, as good as
dextromethorphan (1-2 tsp 3-4x/d) - Dextromethorphan – of all antitussives, has shown to
reduce acute cough. For dry cough - non-Rx cough and colds meds should not be used for
<6yo
Give complications of common cold
complications:
1. otitis media
2. sinusitis
3. pneumonia
Case:
General Data: A 3 year old boy consulted at the Pediatric
Emergency Room due to difficulty of breathing
History of Present Illness
5 days PTA, nonproductive cough with post tussive vomiting and
colds.
2 days PTA, noted with low grade fever (T38.0c) with increasing
frequency of coughing episodes, difficulty of breathing and
wheezes relieved by salbutamol nebulization at home.
On day of admission, during the night, patient was awakened
from sleep due to difficulty of breathing with chest indrawing and
wheezing not relieved by salbutamol nebulization hence
consulted at the PER.
Other pertinent Data:
Past Medical History: (+) recurrent wheezing triggered by dust,
smoke relieved by salbutamol nebulizations. Patient has been
having daytime symptoms of cough (3x/week) and nocturnal
awakening (>2x/month)
(+) previous history of atopic dermatitis
Family Medical History: (+) Bronchial Asthma – Mother and
siblings; (+) Allergic Rhinitis – Father
Birth and Maternal History: Born preterm 33 weeks by PA to a
then 29 G3P2 (2002) mother via SVD at a local hospital. Admitted
at NICU for 1 month for prematurity and neonatal sepsis,
subjected to NCPAP and then sent home as a grower on room air.
Physical Examination:
Seen awake, hunched forward in respiratory distress
HR 150 RR 52 Temp 38.0c O2sats 85% on room air Weight 13.5 kg
(Z score: normal)
Pink conjunctive, anicteric sclera, dusky and dry lips, slightly
sunken eyeballs, no cervical lymphadenopathy (+) alar flaring
Equal chest expansion, (+) subcostal retractions, tight air entry, (+)
expiratory wheezes all over
Laboratory:
CBC: Hgb 125 Hct .39 WBC 18.0 Seg 31% Lymphos 69% PC 455
Chest Radiograph
Answer Key:
Primary working impression and basis:
Primary working impression and basis:
BRONCHIAL ASTHMA in acute exacerbation (10 pts)
Recurrent/episodic airway hypereactivity
Triggers
Reversed by SABA inhalation
Personal History of Atopy – Atopic Dermatitis
Familial History of Atopy – Bronchial Asthma and
Allergic Rhinitis
PE: tight air entry, (+) expiratory wheezes
PNEUMONIA (VIRAL)/BRONCHIOLITIS or PCAP C (10 pts)
Hx: Fever, cough, colds
Ask about Immunization History
PE: tachypneic, with desaturations, alar flaring,
retractions, wheezes and crackles
CBC: leukocytosis with lymphocytic predominance
CXR: hyperaerated lungs with streaky/hilar infiltrates
are more suggestive of viral etiology
Differential Dx
FOREIGN BODY (10 pts)
Age predilection: between 8 months – 4 years
Acute onset – Was there choking or wheezing of
sudden onset
PE: unilateral wheeze/ bilateral or stridor
CXR: radiopaque foreign body/ unilateral atelectasis
GERD (10 pts)
Is the wheezing associated with feeding?
Are there choking or coughing during feeding/ milk
intolerance?
Recurrent bouts of pneumonia?
Poor response to asthma medications?
PE: poor weight gain/ failure to thrive
CONGENITAL (10 pts)
1. Vascular rings
2. Tracheomalacia
Age at onset of wheezing (symptoms often present at
birth)
Does the wheezing get better or worse on changing
position?
Noisy breathing during crying or URTI
Poor response to asthma medications
BRONCHOPULMONARY DYSPLASIA (10 pts)
History of prematurity
Subjected to oxygen and pressure support at NICU
How do you diagnose
asthma in children less
than 5yo (5 pts)
CLINICAL
Hx of Recurrent cough/
wheezing
With a known trigger
(exercise,
allergens,smoke)
Personal Hx of Atopy:
Atopic dermatitis/
eczema, allergic rhinitis
Family Hx of asthma in
1st degree relatives
Clinical improvement
with therapeutic trial
If it the patient were 8
years old, how do you
go about with the
diagnosis of asthma (5
pts)
HISTORY OF CHARACTERISTIC SX +
EVIDENCE OF VARIABLE AIRFLOW
LIMITATION
CLINICAL CRITERIA:
>1 Sx (wheeze, shortness
of breath, cough, chest
tightness)
Sx worse at night or
early morning
Sx vary over time and
intensity
Triggers: viral infections
(colds), exercise,
allergen, changes in
weather, laughter or
irritants
VARIABLE AIRFLOW LIMITATION
Bronchodilator
reversibility test: inc in
FEV1 >12% predicted
(GINA); >15% (PCMCA)
Excessive variability in
twice daily PEF over 2
weeks: diurnal PEF
variability >13% (GINA);
>20% (PCMCA)
Inc in lung function after
4 weeks of anti
inflammatory
Positive exercise
challenge test: fall in
FEV1 of >12% predicted
or PEF >15%
How would you classify
the exacerbation? (1
pt) Basis? (2 pts)
SEVERE
Breathless at rest,
hunched forward
RR>30
Use of accessory
muscles and retractions
HR>120
O2sats <90%
cyanosis
How would you classify
the severity of this
patient’s asthma
according to Philippine
Consensus for the
Management of
Childhood Asthma
(PCMCA)? (1 pt) Basis?
(2 pts)
MILD PERSISTENT
Daytime symptom >1x/
week but less than daily
Nightime symptoms
>2x/month
In exacerbation, what
are the initial
treatment plan? (4 pts)
Inhaled SABA +
ipratropium neb
q20mins x 3 doses
Systemic corticosteroids
Oxygen
supplementation to
maintain O2sats 94-98%
Correct dehydration
How would you
address the
Pneumonia? (4pts)
SUPPORTIVE
Antipyretics
Adequate hydration
Oxygen support as
needed
Rest
Close Observation
What are the home
medications for the
patient? (5 pts)
Oral corticosteroids (1–2
mg/kg/day to a
maximum of 40 mg) for
3–5 days in children
Low dose inhaled
corticosteroids (ICS) 200
– 400ucg/day
Inhaled SABA PRN
LABA or slow release
theophylline
Add on: Antileukotrienes
What parameters are
you going to look for in
order to say that the
patient can be safely
discharged from the
hospital? (4 pts)
PE is normal or near
normal
No nocturnal
awakenings
PEFR >80% predicted
Sustained response to
inhaled SABA (at least 4
hours)
Discharge Instructions
(3 pts)
Identify and avoid
trigger that precipitated
that attack
Review inhaler
technique (for 3yo use
pressurized MDI plus
dedicated spacer with
face mask)
Emphasize follow up
with the physician
Recommendations for
follow up after an
exacerbation? (2 pts)
1 week
Recommendations for
follow up after an
initiation of treatment?
(2 pts)
1-3 months after starting
therapy and 3 – 12
months thereafter
What is bronchiolitis and its etiology?
Acute inflammation of the small airways in children
<2yo resulting in bronchioalveolar obstruction with
edema, mucus, and cellular debris à atelectasis à
V/Q mismatch
- Constellation of clinical s/sx including a viral URT
prodome followed by increased respiratory effort and
wheezing in children <2yo
- Most common RTI in infants
- RSV (50-80%), human metapneumovirus, rhinovirus,
adenovirus, coronavirus, enterovirus, parainfluenza,
influenza
- More common in boys, non-breastfed, crowded areas,
maternal smoking hx during pregnancy
- Common during rainy months in tropics (winter in
temperate)
- Self-limited, diagnosed clinically
What are the clinical manifestations of bronchiolitis?
CM:
1. Coryzal prodrome lasting 1-3 d followed by persistent
cough, tachypnea, with wheezing/crackles
2. LG fever, rhinorrhea, cough
3. Improvement by 5th-7th d
4. Tachypnea, wheezing (first time)/crackles, retractions
(severe)
5. Hyperresonance to percussion
6. Prolonged expiratory phase
How do we diagnose bronchiolitis?
- Usually clinical
1. CXR – hyperinflation with patchy atelectasis,
peribronchial infiltrates. NOT routinely indicated if
uncomplicated
2. ABG – if severe, assess acidosis
What is the cornerstone of management in bronchiolitis?
supportive
Give management of bronchiolitis
- Based on severity
a. Mild – home mgt. Inc OFI, bronchodilator
not recommended
b. Severe – ventilatory & O2 support (cool
humidified O2 for hypoxemic px), hydration,
Ribavirin
- Not recommended: bronchodilators, chest PT, CS, abx,
epi - Admission:
a. Marked respiratory distress (nasal flaring,
retractions, tachypnea, dyspnea, cyanosis)
b. Age <12 w
c. Toxic appearance, poor feeding,
dehydration, lethargy
d. Apnea
e. O2 sat <92%
f. Hx of prematurity
g. Comorbidity CV, pulmo, neuro, immune
h. Unreliable caregivers - Mgt if hospitalized: nebulized hypertonic saline (3%)
2.5-3ml prn - Prevention
a. Palivizumab (monoclonal Ab) for <2yo w/
CHD
b. Hand hygiene
c. Exclusive bf x 6 mos
What is Pneumonia?
inflammation of lung parenchyma
Give the etiology of Pneumonia
Etiology:
1. Neonates (0-28d) – GBS, E.coli, Listeria, S.pneumonia,
HiB
2. 3w-3mos – RSV, parainfluenza, chlamydia trachomatis,
M.pneumoniae, S.pneumoniae, Hib, S.aureus
3. 4m-4yo – RSV, S.pneumoniae, HiB, M.pneumoniae
4. >5yo – M.pneumoniae, S.pneumoniae, Chlamydia
pneumoniae (atypical PN)
What is the most common cause of pneumonia across all age groups?
Viruses
What is the most common bacterial cause of pneumonia across all age groups?
S. pneumoniae
Give the pathogenesis of Pneumonia
- Trauma, anesthesia, and aspiration increase the risk of
pulmonary infection - Viral PN: results from spread of infection along the
airways + direct injury of the respiratory epithelium à
airway obstruction from swelling, abn secretions, and
cellular debris à atelectasis, interstitial edema, VQ
mismatch à significant hypoxemia - Bacterial PN: bacteria colonizes trachea and enter
lungs, or from direct seeding of lungs after bacteremia
Mycoplasma – viral MOA à inhibits ciliary action, cellular
destruction à airway obstruction
S.pneumoniae – local edema allowing bacterial proliferation and
spread into adjacent lung portions à focal lobar involvement
GAS – diffuse infection with interstitial PN. Necrosis of
tracheobronchial mucosa, formation of large amounts of exudate,
edema, and local hemorrhage, extension into the interalveolar
septa à involvement of lymphatic vessels and pleural
involvement
S.aureus – confluent bronchoPN (unilateral), extensive
hemorrhagic necrosis, irregular areas of cavitation in the lung
parenchyma à pneumatocoeles, empyema, bronchopleural
fistulas
What are the clinical manifestations of pneumonia?
CM:
1. Clinical triad: fever, cough, tachypnea
2. Abdominal pain – lower lobe PN
3. Tachypnea – most consistent
4. Early – diminished BS, scattered crackles and rhonchi
5. Late – dullness on percussion, chest lag/asymmetrical
chest on affected side (from consolidation/pleural
effusion)
6. Respiratory failure – retractions, head bobbing,
cyanosis, grunting, apnea, changes in sensorium
7. Recurrent PN - >2 episodes in a single year or >3
What are the 2016 Pneumonia classification?
How do you diagnose pneumonia and other laboratory tests?
Dx:
1. CXR (PAL) – lung infiltrates. Complications such as
pleural effusion or empyema
- Viral PN: hyperinflation with bilateral interstitial
infiltrates and peribronchial cuffing
- Pneumococcal, atypical PN: confluent lobar
consolidation
- Bacterial: pleural effusion, lobar consolidation
2. Pulse oximetry
3. GS, C/S of sputum, nasopharyngeal aspirate, pleural
fluid &/or blood – definitive Dx for bacterial PN
4. BCS – only (+) in 10% of pneumococcal PN. Not
recommended for non-severe OPD cases.
Recommended for severe, clinical deterioration,
complicated PN
5. Chest UTZ -if suspecting multi-lobar consolidation,
necrotizing PN, lung abscess, pleural effusion, air leak
6. ABG
7. CBC – WBC N or elev (viral: <20K, bact 15-40K),
lymphocyte predominance (viral), granulocyte
predominance (bact)
8. CRP, ESR procalcitonin (marker of bacterial pathogen)
– elev in pneumococcal PN
9. PCR (+) – for M.pneumoniae
In Pneumonia, when is antibiotics recommended?
PCAP A or B – abx administered if:
a. >2yo
b. With HG fever without wheeze
PCAP C – empiric abx may be started if any of the ff is present:
a. Elevated serum CRP, PCT, WBC >15k, Lpc-2
b. Alveolar consolidation on CXR
c. Persistent HG fever without wheeze
PCAP D – refer to specialist
PCAP A/B
1. Complete HiB vax: Amoxcillin 80-90 mkd q12 po x 5d
2. No/incomplete HiB vax: Co-amoxiclav 80-90 mkd po
q12/ Cefuroxime 20-30 mkd po q12
3. Allergy: Azithromycin 10mkd po x 3d or 10mkd po on
D1 then 5mkd po on D2-4/ Clarithromycin 15mkd po
q12 x 7d
4. If non-responsive to initial tx (48-72h):
Shift Amoxicillin to Co-amoxiclav 90mkd po q12
If started on Co-amox, Admit for IV abx + macrolide po
PCAP C
5. Complete HiB vax: Penicillin G 200,000 U/k/d IV q6
Ampicillin 200mkd q6 IV
6. No HiB vax: Ampicillin-Sulbactam 100mkd q6 /
Cefuroxime 10mkd IV 18/ Ceftriaxone 100mkd q12 IV
PCAP D: refer to Pulmo/ ID
Atypical PN, >5yo/adolescents
- Azithromycin 10mkd OD x 3 d
Clarithromycin 15mkd BID x 10d
Erythromycin 50mkd po q6-8 po
7. Adolescent: FQ: Ciprofloxacin 20-30mkd po q12.
Caution for <18yo. Reserve for complicated cases.
Why? Due to possible arthrotoxicity.
8. >15yo:
Ampicillin-sulbactam 100-200 mkd IV q6h
Cefuroxime 20-30mkd po, 75-150 mkd q8 IV
carbapenem + macrolide/FQ
Ceftriaxone 2g IV OD x 7d + Azith 500mg ODx5d
Staphylococcal: Clindamycin 10-30mkd po q6-8h, 25-
40mkd IV q6-8h
9. MRSA: Vancomycin 45-60 mkd q6-8h IV
Complications of pneumonia?
How do we prevent it?
Complications:
From direct spread/bacteremia
- Pleural effusion/empyema – S.aureus, S.pneumonia,
S.pyogenes – most common
- Pericarditis
- Meningitis
- Suppurative arthritis
- Osteomyelitis
- Vaccines: influenza, PCV13
what is the leading cause of morbidity and mortality with foreign body aspiration?
Choking
Epidemiology of FB aspiration?
Epidemiology:
- Choking – leading cause of morbidity and mortality in
<4yo
- Most common: food, coins, balloons, toys
- Food: peanuts, carrot, apple, dried beans, popcorn,
sunflower, watermelon seeds, hard candy, chewing
gum, hotdog, grapes (globular-shaped)
- AAP: recommends children <5yo should avoid hard
candy, gum; raw fruits and vegetables to be cut into
smaller pieces
What is the pathophysiology of foreign body aspiration?
Due to underdeveloped ability to swallow food, smaller
diameter airway more prone to obstruction, less force
of air during coughing
What are the clinical manifestations of foreign body aspiration?
CM:
1. Initial event: violent paroxysms of coughing, choking,
gagging, new-onset wheezing
new-onset wheezing
2. Asymptomatic interval: FB lodged, reflexes fatigue, sx
subside.
Most treacherous stage. Account for delayed dx.
3. Complications:
Complete airway obstruction – most serious
complication. Sudden respiratory distress followed by
inability to speak/cough
Erosion, infection: fever, cough, hemoptysis, PN,
atelectasis
How is foreign body diagnosed?
Dx:
- Clinical dx
1. Bronchoscopy – done ASAP once with strong suspicion
- Usually R bronchus (58%), larynx or trachea (10%)
2. CT scan – define radiolucent FB (fish bone)
3. PA and lateral neck XR – if tracheal
4. PA & lateral CXR – If bronchial. Obstructive
emphysema, air trapping, shift of mediastinum
towards opposite side
- The hallmark of an aspirated foreign body is a lung
volume that does not change during the respiratory
cycle
- due to the check valve mechanism, where air enters
the bronchus around the foreign body but cannot exit,
the affected lung will usually appear overinflated and
hyperlucent, with concomitant rib flaring and a
depressed ipsilateral hemidiaphragm
- interrupted bronchus sign: disruption of the air column
in the main bronchi
- the majority of foreign bodies are radiolucent
How do we manage foreign body?
Mgt:
1. referral to Pulmonology for prompt endoscopic
removal of FB
2. Heimlich maneuver – if laryngeal FB
What is the most common cause of upper airway obstruction in children?
Laryngotracheobronchitis (LTB)
Most common viral etiology of LTB
Parainfluenza
What is the pathogenesis of LTB?
Acute inflammatory disease of the larynx (within the
subglottic space)
- The infection causes inflammation of the larynx,
trachea, bronchi, bronchioles, and lung parenchyma.
Obstruction caused by swelling and inflammatory
exudates develops and becomes pronounced in the
subglottic region. Obstruction increases the work of
breathing.
most common site of LTB?
subglottic
what are the clinical manifestations of LTB?
- URTI and LG fever 1-3 d prior to upper airway
obstruction (prodrome 1-7d) - “barking cough”
- Hoarse voice
- Sx worse at night
- Coryza & rhinorrhea
- N to moderately inflamed pharynx
- Slight tachypnea
- Inspiratory stridor (on exertion if mild, at rest for modsevere)
How do we diagnose croup/LTB?
- Clinical
Westley croup score
2.Neck xray: steeple sign/subglottic narrowing
- Endoscopy-definitive; deep red mucosa and subglottic edema
- CBC- usually nonspecific. WBC N or low with lymphocytosis
what is the finding in neck xray in LTB?
Steeple sign
What are the diagnostics and management of LTB?
Dx:
1. Clinical
2. Neck XR – steeple sign/subglottic narrowing: the
narrowing of airway lumen alters the appearance of
tracheal air column, which resembles a church steeple
or a steeply pitched roof.
- Do not correlate with ds severity
3. Endoscopy – definitive; deep red mucosa and
subglottic edema
4. CBC – usually nonspecific. WBC N or low with
lymphocytosis.
Mgt:
1. Admission criteria:
a. Severe ds: poor air entry, altered
consciousness
b. Deterioration after initial medical
management
c. Severe dehydration
d. Fx suggesting secondary bacterial infection
2. Discharge criteria:
a. No stridor at rest
b. N O2 sat
c. Good air exchange
d. No cyanosis
e. N level of consciousness
f. Able to tolerate fluids by mouth
3. Mild: Dexamethasone 0.6mkdose,
Budesonide 2mg neb
4. Moderate to severe:
a. Dexamethasone 0.6mkdose
b. Humidified oxygen (if O2sat <92%)
c. NPO
d. Nebulize epinephrine x 15 min
(0.5ml/kg/dose using 1:1000 dilution, max
5ml)
5. Impending respiratory failure:
a. High O2 using nonrebreathing mask
b. Dexamethasone
c. ET intubated
What is acute epiglottitis?
medical emergency; serious, acute, rapidly progressive infection of supraglottic structures
what is the etiology of acute epiglottitis?
HiB in unvaccinated children
S.pyogenes, S. pneumoniae, S. aureus in vaccinated
What is the pathophysiology of epiglottitis?
Pathophysio
- Hib infection of the epiglottis leads to acute onset of
inflammatory edema, beginning on the lingual surface
of the epiglottis where the submucosa is loosely
attached. Swelling significantly reduces the airway
aperture. Edema rapidly progresses to involve the
subglottic structures (aryepiglottic folds, arytenoids,
and entire supraglottic larynx). The tightly bound
epithelium on the vocal cords halts edema spread at
this level. Frank airway obstruction, aspiration of
oropharyngeal secretions, or distal mucous plugging
can cause respiratory arrest.
What are the clinical manifestations of acute epiglottitis?
CM:
1. Acute onset (4-12h) of HG fever, severe sore throat,
dyspnea, rapidly progressing respiratory obstruction
2. Dysphagia, drooling, hyperextended neck to maintain
airway, muffled voice, sniffing dog or tripod position
3. Double set-up PE (risk of airway obstruction and
respiratory arrest: direct visualization of inflamed
cherry-red epiglottis (Hib) or pale and edematous
epiglottis (Streptococcus)
4D’s: Dysphagia, Dysphonia, Drooling, Distress
how do we diagnose acute epiglottitis?
Dx:
1. C/S – blood, epiglottic surface, CSF
2. CBC – leukocytosis with neutrophilia
3. ABG – respiratory acidosis
4. Lateral neck XR – thumb/ thumbprint/ leaf sign:
thickened free edge of the epiglottis, which causes it to
appear more radiopaque than normal, resembling the
distal thumb
5. Fiberoptic laryngoscopy – direct visualization of cherry
red epiglottis
what is the management for acute epiglottitis?
Mgt:
1. Intubation/tracheostomy under double set-up – 1st
priority. Ave 1-3 d
- Extubate when air leak develops around tube
2. Abx x 7-10d
1st line: Ceftriaxone 50-75 mkd IV q12/24
2nd line: Ampicillin-Sulbactam 100mkd IV q6 x 10d
Alt: Cefotaxime 100-200 mkd IV q6-8h
Meropenem 60mkd IV q8
What is the prophylaxis for epiglottitis?
Prophylaxis:
Rifampicin 20mkd po OD x 4 d for all household members with:
1. Any contact <4yo incompletely immunized
2. Any contact <12 mo w/o any primary vaccination
3. All immunocompromised
What are the complications of epiglottitis?
meningitis, otitis media, PN, cellulitis
What is the most common cause of bacterial tracheitis?
S. aureus
Others: MRSA, S.pneumonia, S.pyogenes,
M.catarrhalis, nontypeable H.influenzae, anaerobes
- Age: 6mos-8yo (peak 5-7yo)
What is the pathophysiology of bacterial tracheitis?
Site: trachea
- mucosal damage or impairment of local immune
mechanisms due to a preceding viral infection, an
injury to the trachea from recent intubation, or trauma
may predispose the airway to invasive infection with
common pyogenic organisms.
What are the clinical manifestations of bacterial tracheitis?
- Slow onset with sudden deterioration. Often follow
viral URTI - Brassy cough, hoarse voice
- HG fever and toxicity can occur immediately or after a
few days of apparent improvement - Stridor, neck pain
- Can lie flat, does not drool, no dysphagia
- Mucosal swelling at the level of the cricoid cartilage
with copious thick, purulent secretions
